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A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests that the client has postherpetic neuralgia?
- A. Linear clusters of vesicles on the right shoulder.
- B. Purulent drainage from both eyes.
- C. Decreased white blood cell count.
- D. Report of continued pain following resolution of the rash.
Correct Answer: D
Rationale: The correct answer is D: Report of continued pain following resolution of the rash. Postherpetic neuralgia is a complication of herpes zoster characterized by persistent pain that continues even after the rash has resolved. This pain can be severe and debilitating, affecting the quality of life of the individual. Choices A, B, and C are incorrect because linear clusters of vesicles on the right shoulder would suggest an active herpes zoster outbreak, purulent drainage from both eyes would indicate an eye infection unrelated to postherpetic neuralgia, and a decreased white blood cell count is not typically associated with postherpetic neuralgia.
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A client who had a myocardial infarction (MI) 2 days ago has many questions about this condition. What area is a priority for the nurse to discuss at this time?
- A. Daily needs and concerns
- B. The overview of cardiac rehabilitation
- C. Medication and diet guidelines
- D. Activity and rest guidelines
Correct Answer: A
Rationale: Addressing the client's daily needs and concerns is a priority to help alleviate anxiety and ensure the client understands the immediate post-MI care. Daily needs and concerns encompass basic aspects like comfort, hygiene, emotional support, and overall well-being, which are crucial in the early recovery phase post-MI. Discussing cardiac rehabilitation, medication and diet guidelines, or activity and rest guidelines are important topics but addressing immediate personal needs and concerns takes precedence to establish a supportive and informative care environment.
The client is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which finding indicates that the bladder irrigation is effective?
- A. The client reports minimal pain and discomfort.
- B. The urine appears clear and free of clots.
- C. The client has no signs of infection.
- D. The client is able to void independently.
Correct Answer: B
Rationale: The presence of clear urine free of clots is an indicator that the bladder irrigation is effective. This finding suggests that the irrigation is preventing clot formation and ensuring proper drainage, which is crucial after a TURP procedure. The client reporting minimal pain and discomfort (choice A) may be a positive sign but does not directly reflect the effectiveness of the bladder irrigation. The absence of infection signs (choice C) is important but not specific to evaluating the bladder irrigation. The client being able to void independently (choice D) is a good sign overall but does not specifically indicate the effectiveness of the bladder irrigation.
A client with diabetes mellitus is being taught by a nurse about mixing regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should roll the NPH vial between my hands before drawing it up.
- B. I should draw up the NPH insulin before the regular insulin.
- C. I should inject air into the vial of regular insulin first.
- D. I should wait 10 minutes after mixing the insulin to inject it.
Correct Answer: A
Rationale: The correct answer is A. Rolling the NPH vial between the hands before drawing it up ensures proper mixing of the insulin. Choice B is incorrect because regular insulin should be drawn up first to avoid contamination. Choice C is incorrect as injecting air into the vial of regular insulin is not necessary. Choice D is incorrect as there is no need to wait 10 minutes after mixing the insulin before injecting it.
During a staff meeting, a nurse is discussing the purpose of regulatory agencies. Which of the following tasks should the nurse identify as the responsibility of state licensing boards?
- A. Monitoring evidence-based practice for clients with specific diagnoses.
- B. Ensuring that health care providers comply with regulations.
- C. Setting quality standards for accrediting health care facilities.
- D. Determining the safety of medications for administration to clients.
Correct Answer: B
Rationale: State licensing boards are primarily responsible for ensuring that health care providers comply with regulations. This includes overseeing licensure requirements, investigating complaints, and enforcing disciplinary actions. Monitoring evidence-based practice for clients with specific diagnoses is typically within the domain of professional organizations or healthcare institutions. Setting quality standards for accrediting health care facilities is usually the role of accrediting bodies such as The Joint Commission. Lastly, determining the safety of medications for administration to clients falls under the purview of regulatory agencies like the Food and Drug Administration (FDA).
During a client admission, how should the nurse conduct medication reconciliation?
- A. Compare the client's home medications to the provider's prescriptions.
- B. Review the client's medical history.
- C. Assess the client's current medications.
- D. Ask the client about their allergies.
Correct Answer: A
Rationale: During medication reconciliation, the nurse should compare the client's home medications with the provider's prescriptions to ensure accuracy and prevent medication errors. Reviewing the client's medical history (Choice B) is important but not the primary focus of medication reconciliation. Assessing the client's current medications (Choice C) is also vital but is not specific to the comparison between home and prescribed medications during reconciliation. Asking the client about their allergies (Choice D) is relevant for ensuring safe medication administration but is not the primary step in medication reconciliation, which involves comparing actual medications.